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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Nevada Statutes and Codes Pertinent to Health Insurance Only | 14% | - Medicare
- Coverage for reconstructive surgery - Long Term Care - Availability of coverage for mental health and treatment of alcohol abuse and drug abuse - Mandatory policy clauses and provisions
|
| Topic 2: Nevada Statutes and Codes Common to Life and Health Insurance Only | 4% | - Credit life and health insurance - Group life and health insurance
|
| Topic 3: Nevada Statutes and Codes Common to Life, Health, Property, and Casualty Insurance | 20% | - Definitions
- Insurance Commissioner
|
| Topic 4: Accident & Health – General Knowledge | 50% | - Other Insurance Concepts
|
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NEW QUESTION # 74
In a typical HMO arrangement, what is the primary role of the primary care provider?
Answer: C
Explanation:
In a typical health maintenance organization, the primary care provider acts as the central coordinator of the insured's routine medical care. The primary care provider may deliver preventive and basic medical services, maintain the patient's care plan, and refer the patient to specialists or other facilities when required by the HMO's rules. This gatekeeper function is intended to coordinate care, reduce unnecessary duplication, and manage costs through the plan's provider network.
The precise referral rules depend on the particular HMO. Some plans may allow direct access to certain specialists, such as obstetricians or behavioral-health providers, while others require prior referral or authorization. Emergency services are subject to separate protections and should not be described as ordinary out-of-network elective care. The producer must explain the network, referral, prior-authorization, and out-of- network rules before enrollment.
A PPO also has a preferred provider network but commonly allows members to use nonnetwork providers at a reduced benefit level and without the same referral structure. An indemnity plan may provide broader provider choice but may have different reimbursement limits and cost sharing. The test distinction is that an HMO commonly emphasizes coordinated, network-based care through a primary care provider.
References/topics from the Study Guide: Managed Care; HMO; Primary Care Provider; Gatekeeper Model; Provider Networks.
NEW QUESTION # 75
Which of the following statements is CORRECT about Business Overhead Expense insurance?
Answer: B
Explanation:
Business Overhead Expense insurance reimburses a business for specified ongoing operating expenses when a business owner becomes disabled. Eligible expenses commonly include employee salaries, rent, utilities, office expenses, and other ordinary fixed costs identified in the policy. Accordingly, choice B is correct. The purpose is business continuity: it helps keep the office or practice operating during the owner's disability rather than replacing the owner's personal income. A disability income policy, not Business Overhead Expense insurance, is the product intended to replace an individual's lost earned income. The coverage is not restricted to corporations; it may be appropriate for sole proprietors, partners, and owners of closely held businesses, depending on underwriting and policy eligibility. It also is not limited to staff expenses alone, because rent, utilities, and other contractually covered overhead are central components of the protection.
Benefits are generally limited by the actual covered overhead incurred and the policy's monthly benefit amount. Study Guide References/Topics: Taxation and Business Uses of Health Insurance; Disability Income Insurance; Business Overhead Expense Coverage.
NEW QUESTION # 76
Under a group health policy, which of the following coverages MUST be provided for newborn children?
Answer: A
Explanation:
Nevada requires qualifying group health policies that cover family members to provide coverage for a newborn child from the moment of birth. Required newborn coverage includes injury or sickness and specifically includes the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. Therefore, congenital health defects are the required coverage identified in this question.
The rule is important because congenital defects may be present at birth and can require immediate diagnostic, surgical, medical, or hospital treatment. Nevada law prevents a policy from excluding this necessary care simply because the condition existed at birth. The statute also prohibits exclusion of premature births under the applicable coverage requirement.
The transportation option is incorrect because the law addresses necessary transportation from the place of birth to the nearest specialized treatment center, within policy limits; it does not mandate transportation from the hospital to the child's residence. Routine eye examinations and genetic testing may be covered under a particular policy or health plan, but they are not the specific newborn mandate tested here. Continued coverage beyond the initial period may depend on timely notice and payment of required premium within 31 days.
Study Guide references/topics: group health insurance; newborn coverage; mandated benefits; NRS 689B.033
.
NEW QUESTION # 77
An application for an individual Disability Income policy may require all of the following information about the proposed insured EXCEPT for:
Answer: D
Explanation:
The correct answer is D. Underwriting for an individual disability income policy focuses on facts that affect the proposed insured's probability of disability, ability to work, existing income protection, and potential for overinsurance. Marital status and occupation may be relevant to financial and occupational underwriting.
Medical history is directly relevant because past and current health conditions can affect eligibility, exclusions, ratings, or benefit limitations. Other disability policies already in force are important because insurers must evaluate the total amount of disability benefits relative to earned income and avoid excessive coverage. The spouse's occupation ordinarily does not determine the proposed insured's disability risk or benefit eligibility and is therefore the least relevant item. Insurers also may request information about income, employer, job duties, hazardous activities, tobacco use, prior claims, and other sources of disability income.
The producer must obtain complete and accurate answers from the applicant, explain questions when necessary, and avoid making assumptions or completing answers without the applicant's direction. Study Guide References/Topics: Completing the Application, Underwriting, and Delivering the Policy; Disability Income Underwriting; Application Information.
NEW QUESTION # 78
A producer offers a prospective life insurance applicant a gift card that is not stated in the policy as an inducement to purchase coverage. Which prohibited practice is most directly implicated?
Answer: D
Explanation:
Rebating occurs when a producer or insurer offers, gives, or allows an inducement not specified in the policy to persuade a person to purchase insurance. A gift card offered solely because the applicant buys a life or health policy is a classic example of a potentially prohibited rebate. Nevada trade-practice law restricts rebates and other improper inducements because they can create unfair competition, mislead consumers, and distort insurance pricing.
The prohibition does not mean that every item of nominal value, educational material, or lawful consumer program is automatically illegal. The legality of a benefit depends on the statute, regulations, insurer programs, value, purpose, and whether it is tied improperly to the sale. Producers should follow current Nevada rules and insurer compliance guidance before offering anything of value in connection with a sale.
Coinsurance is a health-policy cost-sharing method. Subrogation is an insurer's right to recover from a responsible third party after paying a loss. Assignment transfers some or all policy rights from one party to another. None of those terms describes an improper sales inducement.
A producer should avoid promising gifts, refunds, premium reductions, or extra benefits unless specifically authorized and properly disclosed under applicable law and policy provisions.
References/topics from the Study Guide: Unfair Trade Practices; Rebating; Inducements; Producer Ethics; NRS 686A.110.
NEW QUESTION # 79
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